Patient Consent of Medical Information Form

Mountain Park Dentistry Dr. Mow D.D.S.

PATIENT CONSENT FOR RELEASE OF MEDICAL INFORMATION

Due to the HIPPA laws that are now in effect we must have your written authorization to release your medical information to a person other than yourself. Understand that your information may need to be discussed with your current physician and/or referred to/or/ from specialists in regards to scheduling of procedures, consultations and health history that may impact your dental health. Only the information needed to do this will be released.